Isn’t It About Time for Hospice to Get on Board with Medical Marijuana?

By Cheryl K. Smith

The day before my dad died from a perforated intestine, he had a bout of pain that we were unable to control with the medicines that had been prescribed through hospice—morphine, lorazepam and haloperidol. I could not bear to see him suffer, so as my sister called the hospice nurse to ask what we should do (how much morphine we could give), I had an idea. It was time to try some cannabis. My dad had previously been unwilling to try cannabis in any form for symptoms of terminal prostate cancer. At the age of 89, and never a substance user other than a little alcohol, he undoubtedly had been affected by the reefer madness hype over the years. He said he hoped my feelings wouldn’t be hurt if he didn’t eat the medicated lemon drops I left in the cupboard for him to try for the pain caused by spinal metastases from prostate cancer. This time, when I asked him whether he would be willing to try a cannabis vape pen, he agreed. My daughter and I explained to him that it would not take away his pain, but it would change his perception of the pain so it would be bearable. He just wanted to be out of pain, so he agreed. I showed him how to use the vape pen, and had him take a hit, and then another one. Within less than a minute he visibly relaxed. The pain was no longer bothering him. He only needed to use the vape pen one more time—later that night—and ultimately died a peaceful death, conscious almost until the end, and surrounded by loving family. So, why are vape pens not a part of the med kit provided to hospice patients for a peaceful end to their lives? Medical marijuana is legal in 29 states and the District of Columbia, and the federal government has said it will not interfere in the programs in those states. It seems to me that he tide has turned, so why are health care providers still dragging their feet, especially when it comes to end of life care? Now that more than half of US states have legalized some form of medical marijuana, and the evidence continues to mount on the effectiveness of cannabis on pain and nausea, hospices and palliative care providers need to catch up. The two main reasons given for ignoring or prohibiting hospice staff from assisting patients with medical cannabis are potential loss of Medicare funding for violating federal law and loss of a DEA license for providing a Schedule I controlled substance (one with no medical use and a high risk for abuse). While these may be valid fears—especially in light of a Donald Trump administration—there is no evidence that adverse actions have ever been taken when a hospice provides some support for their patients who use cannabis. According to an October 2016 article in the Hospice Compliance Newsletter, “Hospices have an ethical mandate to support patient autonomy, helping their patients live out their remaining lives in ways that are meaningful to them.” This includes knowing about “complementary and alternative therapies the patient might be taking and how these could interact with hospice-ordered therapeutics.” The article also points out that this would obligate them to document it on the Medication Administration Record (MAR)—which some hospices are doing. (At least one Washington hospice only allowed for the inclusion of dronabinol [synthetic cannabis] on the MAR. Others do allow plant-based cannabis and take one of two approaches: 1. Most commonly, it is treated like an alternative treatment or supplement and included on the plan of care; or 2. It is acknowledged as a medicine and potential drug interactions are even documented. A few hospices have taken a more proactive stance regarding medical cannabis. In June 2014 Comprehensive Hospice and Palliative Care in Arizona hired an inhouse doctor to recommend cannabis for patients, as well as to monitor for adverse effects. They also met with dispensary staff to learn about particular strains of cannabis that were more helpful to individual patients. In this model, family or someone other than the hospice must pay fees and for the cannabis products, to avoid implicating the federal government vis à vis Medicare. A small Illinois provider—Blessing Hospice & Palliative Care—developed a policy to treat cannabis like other herbal medications, but stays at arm’s length by not paying for or assisting in obtaining the cannabis, as well as avoiding being present when the patient uses it. Such policies may implicate Medicare indirectly, however. Under Medicare Conditions of Participation, hospice is required to pay for all medication—so if cannabis is considered a medication, they should pay for it. But their hands are tied by the federal government, which will not pay for a Schedule I controlled substance. Brian Jones, DHsC, CHPCA, Director of Hospice and Palliative Programs at St. Elizabeth Healthcare in Kentucky, offers a virtual conference for healthcare professionals entitled “Medical Marijuana Approach.” In a phone conversation with Jones, he pointed out that Kentucky is trying to legalize cannabis for terminal illness, but the legislation would redefine “terminal illness,” which is problematic. According to Jones, in at least one inpatient hospice he was aware of, patients are allowed to smoke on the patio, and in some cases, nurses reported that what they smoke is marijuana. The goal is quality of life. This is similar to other hospice programs I know of—which also have don’t ask, don’t tell policies. Frustratingly, after providing an educational presentation on cannabis to an Oregon hospice, they shortly thereafter implemented a policy prohibiting staff from being present while it is being used. It varies from program to program whether nurses or other staff are allowed to present when patients are using cannabis. Terminal patients are seen as a separate category in regard to experimental treatment. If patients with terminal cancer are allowed to agree to treatments with chemotherapy and immunotherapy agents that can seriously sicken and kill them—in hopes for obtaining a cure or just a longer life—then why deny them cannabis, and why not even help them with using this negligibly harmful substance? There is another reason for more openness regarding cannabis in hospice. If hospice providers and other medical professionals don’t educate themselves regarding cannabis for end-of-life or other care and then use that knowledge to help patients, someone else (with limited medical knowledge) will. This can already be witnessed online. For example, there is a Facebook group called “Cannabis Oil Success Stories” in which laypeople are advising desperate people who come with questions about how to save themselves or their loved ones from cancer and other conditions. They provide recommendations on dosages and route of administration, based on anecdotal information. Cures are always attributed to cannabis, even in cases where patients were also receiving chemotherapy and/or radiation. The same situation can be found at some dispensaries, where budtenders suggest strains, dosages and other recommendations regarding the efficacy of medical cannabis for specific medical conditions. In some cases they are educated and in others they are not. And of course, the biggest problem is that the data do not exist to even develop meaningful recommendations. In 2015, at the request of Compassionate Oregon, a medical marijuana patient advocacy organization, the Oregon legislature passed a bill that allows a medical marijuana patient to name a hospice as a secondary caregiver. ORS 475B.419 states that “an organization that provides hospice, palliative or home health care services, or a residential facility [as defined by the law], that has significant responsibility for managing the well-being of a person who has been diagnosed with a debilitating medical condition may be designated, in addition to an individual, as an additional caregiver for a registry identification cardholder in the same manner that an individual is designated as the primary caregiver for a registry identification cardholder under [the law].” It also gives that organization or facility “all the duties, functions and powers of a designated primary caregiver.” Under this law, agents of a hospice may obtain medical cannabis for their patients and even provide them with information on dosage and route of administration. While no hospice or otherorganizations were formally opposed to or supportive of the legislation, it isn’t clear whether they (or even patients) are aware of it or have agreed to let patients choose them as a caregiver. Oregon and other states have also started to take other small steps toward normalizing medical cannabis. In Oregon, Washington and Colorado, clinical guidelines have been developed for medical marijuana recommendations by doctors. The Oregon Medical Board held their first educational session on medical cannabis last year and has plans to offer education on the endocannabinoid system. The Hospice and Palliative Nurses Association (HPNA) have understood the appropriate use of medical cannabis in end-of-life care for years now. In 2014, they developed a position statement that advocates education and practice, within the current law. (See sidebar) Physicians’ associations, if they want to best serve their patients’ needs would be wise to follow suit. I hope that hospice and palliative care providers eventually come around regarding the use of medical cannabis for end-of-life care. When I suggested to the hospice nurse after my father’s death that cannabis should be part of that “end-of-life kit” (containing pharmaceuticals), I was met with a blank stare. It is past time for these caring organizations to get beyond their fears and prejudices, educate themselves and educate their patients—giving cannabis its rightful place in the palliative care arsenal. Cheryl K. Smith is a freelance writer and editor. She was formerly an attorney and Executive Director of Compassion Center, a nonprofit medical marijuana clinic in Eugene, Oregon. She has served on the Oregon Advisory Committee on Medical Marijuana (ACMM) for more than four years.